Client Questionnaire For Business Debtor

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1 Client Questionnaire For Business Debtor Section 1 Basic Information Part A. Name and Address Name of business: Contact Person s name: Telephone Number: ext.: Alternative Number: Has the business gone by any other names in the past eight years? No Yes If yes, list other names: Federal Tax ID or Social Security Number: Address: City: State: Zip: County: Has the business been at this address for at least 180 days? No Yes If there is a different mailing address, please list: Mailing Address: City: State: Zip: Part B. Nature of Business 1. Location of principal assets, if different from address above: City: State: Zip: 2. Please describe the nature of your business: 3. Who is the authorized signer? His/Her title? 4. Do any of the following describe your business? Railroad Stockbroker Commodity Broker Clearing Bank Health Care Business Single Asset Real Estate 501(c)(3) Non-Profit Part C. Prior/Pending Bankruptcy Cases 1. Has a bankruptcy case been filed by your company or against your company in the last 8 years? No Yes If yes, in which district of which state was the case filed? Case Number: Date filed: 2. Are there currently any bankruptcy cases pending involving you, your business, your business partner, or any of your affiliates? No Yes If yes, name of debtor: Relationship to you: Case Number: Date filed: Judge: District in which the case was filed: Exhibit "C" to the Voluntary Petition Does your company own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety? No Yes (If yes, please attach a list and description of the property.) Client Questionnaire: Copyright Best Case Solutions, Inc. Page 1

2 Section 2 Property Part A. Real Estate (Schedule A) List all real estate which the business owns or is a joint owner of, even if the business still owes money on the property. Address and description of property Value The business s % ownership, or $ amount of equity, if your business is not the sole owner. List all mortgages and liens What is the $ value of the loan, lien, or mortgage? Who issued the lien, loan or mortgage? (name and address of institution) Office Use Only Notes Client Questionnaire: Copyright Best Case Solutions, Inc. Page 2

3 Part B. Personal Property (Schedule B) For each type of property listed below, indicate whether the business owns any property of that category, and, if so, fill in the remaining information. You can think of the value as the resale value. Attach additional pages if necessary. Type of Property Yes/No Description & Location Value 1 Cash on hand Office Use Only Notes 2 Checking/Savings Account, Certificates of deposit, other bank accounts 3 Security deposits held by utility companies, landlord 4 Household goods, furniture, including audio, video, and computer equipment Client Questionnaire: Copyright Best Case Solutions, Inc. Page 3

4 Type of Property Yes/No Description & Location Value 5 Books, pictures, art objects, records, compact discs, collectibles Office Use Only Notes 6 Clothing 7 Furs and jewelry 8 Sports, photographic, hobby equipment, firearms 9 Interest in insurance policies-specify refund or cancellation value 10 Annuities 11 Interests in an education IRA, as defined in 26 USC 530(b)(1) 12 Interests in pension or profit sharing plans Client Questionnaire: Copyright Best Case Solutions, Inc. Page 4

5 Type of Property Yes/No Description & Location Value 13 Stock and interests in incorporated/ unincorporated business 14 Interests in partnerships/joint ventures 15 Bonds Office Use Only Notes 16 Accounts receivable 17 Alimony/family support to which you are entitled 18 Other liquidated debts owed to you, including tax refunds 19 Equitable or future interests or life estates 20 Interests in estate of decedent or life insurance plan or trust 21 Other contigent/ unliquidated claims, including tax refunds, counterclaims 22 Patents, copyrights, other intellectual property Client Questionnaire: Copyright Best Case Solutions, Inc. Page 5

6 Type of Property Yes/No Description & Location Value 23 Licenses, franchises Office Use Only Notes 24 Customer list or other compilation with personally identifiable information 25 Automobiles, trucks, trailers, and accessories. 26 Boats, motors, and accessories 27 Aircraft and accessories 28 Office equipment, supplies 29 Machinery, fixtures etc. for business 30 Inventory 31 Animals 32 Crops-growing or harvested 33 Farming equipment and implements 34 Farm supplies, chemicals, feed Client Questionnaire: Copyright Best Case Solutions, Inc. Page 6

7 Type of Property Yes/No Description & Location Value 35 Other personal property of any kind not listed. Office Use Only Notes Client Questionnaire: Copyright Best Case Solutions, Inc. Page 7

8 Section 3 Debts List below all debts that the business owes, or that creditors claim that the business owes. Attach additional sheets if necessary. Type of Debt Mortgages 1. Creditor Name and Address 2. Date/Range of dates when debt was incurred 3. Account Number, if any 4. Contact person s name and address, if different Amount owed What is the debt for? Describe the collateral for this loan, if any. What is the estimated value of the collateral? Is there a codebtor, someone else who can be held responsible for the debt? If so, his/her name and address: Do you dispute the debt? Office Use Only Sched. D, E or F? Notes: lawsuit pending? Collection agency or attorney assigned? Car/vehicle loans Other bank loans Personal (non-bank) loans Client Questionnaire: Copyright Best Case Solutions, Inc. Page 8

9 Office Use Only Type of Debt Major credit card debts (Visa, Am Ex, Mastercard, Discover) 1. Creditor Name and Address 2. Date/Range of dates when debt was incurred 3. Account Number, if any 4. Contact person s name and address, if different Amount owed What is the debt for? Describe the collateral for this loan, if any. What is the estimated value of the collateral? Is there a codebtor, someone else who can be held responsible for the debt? If so, his/her name and address: Do you dispute the debt? Sched. D, E or F? Notes: lawsuit pending? Collection agency or attorney assigned? Department store or other storeissued credit card debts Client Questionnaire: Copyright Best Case Solutions, Inc. Page 9

10 Office Use Only Type of Debt Other credit card debts (Gas cards, phone cards, etc.) 1. Creditor Name and Address 2. Date/Range of dates when debt was incurred 3. Account Number, if any 4. Contact person s name and address, if different Amount owed What is the debt for? Describe the collateral for this loan, if any. What is the estimated value of the collateral? Is there a codebtor, someone else who can be held responsible for the debt? If so, his/her name and address: Do you dispute the debt? Sched. D, E or F? Notes: lawsuit pending? Collection agency or attorney assigned? Unpaid utility bills Unpaid rent Unpaid taxes Client Questionnaire: Copyright Best Case Solutions, Inc. Page 10

11 Office Use Only Type of Debt Unpaid service fees (to attorneys, accountants etc.) 1. Creditor Name and Address 2. Date/Range of dates when debt was incurred 3. Account Number, if any 4. Contact person s name and address, if different Amount owed What is the debt for? Describe the collateral for this loan, if any. What is the estimated value of the collateral? Is there a codebtor, someone else who can be held responsible for the debt? If so, his/her name and address: Do you dispute the debt? Sched. D, E or F? Notes: lawsuit pending? Collection agency or attorney assigned? Trade Debts All other unpaid debts/bills Client Questionnaire: Copyright Best Case Solutions, Inc. Page 11

12 Section 4 Unexpired Leases and Contracts (Schedule G) List below any leases or contracts that are still current that the business is a party to. Include real estate, car and business leases, and service or business contracts. Nature and Description of Contract Name and Address of Other Party or Parties Date that Contract Expires Client Questionnaire: Copyright Best Case Solutions, Inc. Page 12

13 Section 5 Statement of Financial Affairs If you have no information to report for a question, check the "NONE" box. 1 Income from employment or operation of business State your gross income from employment or operation of a business: If you have not received an income from employment during the two years immediately preceding this calendar year, check this box: Period $ Amount Source January 1 of this year through date of commencement of case Last year, (January 1 - December 31) The year before last, (January 1 - December 31) 1 Income other than from employment or operation of business State the amount of income received other than from employment or operation of business during the two years immediately preceding the commencement of this case: Period $ Amount Source During the last year Year before last 1 Payments to creditors a. If your debts are primarily consumer debts, List all payments on loans, installment purchases of goods or services, and other debts, aggregating more than $600 to any creditor made within 90 days immediately preceding the commencement of this case. Indicate with an asterisk (*) any payments that were made on account of a domestic support obligation, or that were made as part of an alternative payment plan. Name and Address of Creditor Dates of Payments Amount paid Amount still owed Client Questionnaire: Copyright Best Case Solutions, Inc. Page 13

14 b. If your debts are not primarily consumer debts, list each payment or other transfer, aggregating more than $5,000 to any creditor within 90 days immediately preceding the commencement of this case. Name and Address of Creditor Dates of Payments Amount paid Amount still owed c. All debtors. List all payments made within one year immediately preceding the commencement of this case to creditors who were "insiders". ("Insiders" include your relatives, your business partners and their relatives, your corporations, or your affiliates.) Name and Address of Creditor and Relationship to You Dates of Payments Amount Paid Amount Still Owed 4. Suits, executions, garnishments and attachments a. List all suits and administrative proceedings to which you are or were a party within one year preceding the filing of this case. Caption of Suit Court or Agency Status or and Case Number Nature of Proceeding and Location Disposition b. Describe all property that has been garnished, seized, or attached under any legal or equitable process within one year immediately preceding the commencement of this case. Name and Address of Person/Company Description for Whom the Property Was Seized (Creditor) Date of Seizure and Value of Property Client Questionnaire: Copyright Best Case Solutions, Inc. Page 14

15 5. Repossessions, foreclosures, and returns List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in lieu of foreclosure, or returned to the seller, within one year immediately preceding the commencement of this case. Date of Repossession, Description Name and Address of Creditor Foreclosure, Transfer or Return and Value of Property 6. Assignments and receiverships a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding the commencement of this case. Name and Address of Assignee Date of Assignment Terms of Assignment/Settlement b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one year immediately preceding the commencement of this case. Name and Address Name and location of Court, Date of Description and Value of Custodian Case Title and Number Order of Property 7. Gifts List all gifts or charitable contributions made within one year immediately preceding the commencement of this case except ordinary and usual gifts to family members aggregating less than $200 in value per individual family member and charitable contributions aggregating less than $100 per recipient. Name and Address Date Description of Recipient Relationship to You, if Any of Gift and Value of Gift Client Questionnaire: Copyright Best Case Solutions, Inc. Page 15

16 8. Losses List all losses from fire, theft, gambling or other casualty within one year immediately preceding the commencement of this case or since the commencement of this case. Description and Value Description of Circumstances and of Property Amount Covered by Insurance, if Any Date of Loss 9. Payments related to debt counseling or bankruptcy List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys, for consultation concerning debt consultation, relief under the bankruptcy law or preparation of the petition in bankruptcy within one year immediately preceding the commencement of the case. Name and Address Date of Name of Person Amount of Money/ Description of Payee Payment Who Paid, if Not You and Value of Property 10. Other transfers, (including sale of your property) a. List all other property, other than property transferred in your ordinary course of business or financial affairs, transferred either absolutely or as a security within two years immediately preceding the commencement of this case. Name and Address of Transferee Description of Property and Relationship to you Date of Transfer Transferred and Value Received b. List all property transferred within 10 years immediately preceding the commencement of this case to a self-settled trust, or similar device of which the debtor is the beneficiary. Name of Trust or Amount of Money or Description Similar Device Date of Transfer and Value of Property or Interest 11. Closed financial accounts List all financial accounts and instruments held in your name or for your benefit which were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case. Name and Address Type and Number of Amount and Date of Institution Account & Final Balance of Sale or Closing Client Questionnaire: Copyright Best Case Solutions, Inc. Page 16

17 12. Safe deposit boxes List each safe deposit or other box or depository in which you have or have had securities, cash, or other valuables within one year immediately preceding commencement of this case. Name and Address of Name and Address of Those Description Date of Bank or Other Depository With Access to Box or Depository of Contents Transfer, if Any 13. Setoffs List all setoffs made by any creditor, including a bank, against a debt or deposit of yours within 90 days preceding the commencement of this case. Name and Address of Creditor Date of Setoff Amount of Setoff 14. Property held for another person List all property that you hold or control that is owned by another person. Name and Address of Owner Description and Value of Property Location of Property 15. Prior address of debtor If you have moved within the three years immediately preceding the commencement of this case, list all residences during the last three years, excluding your present address. Address Your Name at the Time Dates of Occupancy 16. Spouses and Former Spouses If you reside or resided in a community property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within the eight-year period immediately preceding the commencement of the case, identify the name of your spouse and of any former spouse who resides or resided with you in the community property state. Name Client Questionnaire: Copyright Best Case Solutions, Inc. Page 17

18 17. Environmental Information. For the purpose of this question, the following definitions apply: "Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination, releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances, wastes, or material. "Site" means any location, facility, or property as defined under any Environmental Law, whether or not presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites. "Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance, hazardous material, pollutant, or contaminant or similar term under an Environmental Law a. List the name and address of every site for which you received notice in writing by a governmental unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the governmental unit, the date of the notice, and, if known, the Environmental Law: Name and Address of Date Environmental Site Name and Address Governmental Unit of Notice Law b. List the name and address of every site for which you provided notice to a governmental unit of a release of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice. Name and Address of Date Environmental Site Name and Address Governmental Unit of Notice Law c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law with respect to which you are or were a party. Indicate the name and address of the governmental unit that is or was a party to the proceeding, and the docket number. Name and Address of Governmental Unit Docket Number Status or Disposition Client Questionnaire: Copyright Best Case Solutions, Inc. Page 18

19 18. Nature, location and name of business a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or managing executive of a corporation, partnership, sole proprietorship, or was a self-employed professional within the six years immediately preceding the commencement of this case, or in which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities, within the six years immediately preceding the commencement of this case. If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the voting or equity securities within the six years immediately preceding the commencement of this case. Taxpayer Beginning and End Name I.D. Number(EIN) Address Nature of Business Dates of Operation b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11 U.S.C Name Address Client Questionnaire: Copyright Best Case Solutions, Inc. Page 19

20 The following questions, #19-25, are only to be answered if you are a corporation or partnership or if you have been, in the six years immediately preceding this case, an officer, director, managing executive, or owner of more than 5% of the voting securities of the corporation; a partner, other than a limited partner, of a partnership; a sole proprietor, or otherwise self-employed. 19. Books, records, and financial statements a. List all bookkeepers and accountants who, within the two years immediately preceding the filing of this bankruptcy case, kept or supervised the keeping of books of account and records. Name and Address Dates Services Rendered b. List all firms or individuals who, within the two years immediately preceding the filing of this bankruptcy case, have audited the books of account and records, or prepared a financial statement of the debtor. Name Address Dates Services Rendered c. List all firms or individuals who, at the time of the commencement of this case, were in possession of your books of account and records. If the records are not available, explain. Name and Address Comments d. List all financial institutions, creditors and other parties, including mercantile and trade agencies, to whom a financial statement was issued by the debtor within two years immediately preceding the commencement of this case. Name and Address Date Issued Client Questionnaire: Copyright Best Case Solutions, Inc. Page 20

21 20. Inventories a. List the dates of the last two inventories taken of your property, the name of the person who supervised the taking of each inventory, and the dollar amount and basis of each inventory. Dollar Amount of Inventory Date of Inventory Inventory Supervisor (specify cost, market, or other basis) b. List the name and address of the person possessing the records of each of the two inventories reported in a.) above. Date of Inventory Name and Address of Custodian of Inventory Records 21. Current partners, officers, directors, and shareholders a. If your business is a partnership, list the nature and percentage of partnership interest of each member of the partnership. Name and Address Nature of Interest Percentage of Interest b. If your business is a corporation, list all officers and directors of the corporation, and each stockholder who directly or indirectly owns, controls, or holds 5 % or more of the voting securities of the corporation. Nature and Percentage Name and Address Title of Stock Ownership 22. Former partners, officers, directors and shareholders a. If your business is a partnership, list each member who withdrew from the partnership within one year immediately preceding the commencement of this case. Name and Address Date of Withdrawal Client Questionnaire: Copyright Best Case Solutions, Inc. Page 21

22 b. If your business is a corporation, list all officers or directors whose relationship with the corporation terminated within one year immediately preceding the commencement of this case. Name and Address Title Date of Termination 23. Withdrawals from a partnership or distributions by a corporation If your business is a partnership or corporation, list all withdrawals or distributions credited or given to an insider, including compensation in any form, bonuses, loans, stock redemptions, options exercised and any other perquisite during one year immediately preceding the commencement of this case. Name and Address of Date and Purpose Amount of Money or Description Recipient, and Relationship to You of Withdrawal and Value of Property 24. Tax Consolidation Group. If the debtor is a corporation, list the name and federal taxpayer identification number of the parent corporation of any consolidated group for tax purposes of which the debtor has been a member at any time within the six-year period immediately preceding the commencement of the case. Name of Parent Corporation Taxpayer Identification Number 25. Pension Funds. If the debtor is not an individual, list the name and federal taxpayer identification number of any pension fund to which the debtor, as an employer, has been responsible for contributing at any time within the six-year period immediately preceding the commencement of the case. Name of Pension Fund Taxpayer Identification Number Client Questionnaire: Copyright Best Case Solutions, Inc. Page 22

23 Approximate number of holders Section 6 Supplement for Chapter 11 Cases Part A. Exhibit "A" to Voluntary Petition If debtor is required to file periodic reports (e.g. - Forms 10K and 10Q) with the Securities and Exchange Commission pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934 and is requesting relief under chapter 11 of the Bankruptcy code, Exhibit "A" shall be completed and attached to the petition. Are any of your securities registered under section 12 of the Securities Exchange Act of 1934? Yes No If so, what is the SEC file number? The following questions ask for financial data about your company. Your answers reflect the company s finances as of (date). Total assets: $ Total liabilities: $ Please list debt securities held by more than 500 holders Secured Unsecured Subordinated $ Secured Unsecured Subordinated $ Secured Unsecured Subordinated $ Secured Unsecured Subordinated $ Secured Unsecured Subordinated $ Number of shares of preferred stock Number of shares of common stock Comments, if any: Briefly describe the nature of your business: List the name of any person who directly or indirectly owns, controls, or holds, with power to vote, 5% or more of the voting securities of your company: Client Questionnaire: Copyright Best Case Solutions, Inc. Page 23

24 Part B. Equity Security Holders List the names and addresses of all equity security holders: Name and Address Security Class Number of Securities Kind of Interest Client Questionnaire: Copyright Best Case Solutions, Inc. Page 24

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